Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti.

Electronic health information systems, including electronic medical records (EMRs), have the potential to improve access to information and quality of care, among other things. Success factors and challenges for novel EMR implementations in low-resource settings have increasingly been studied, although less is known about maturing systems and sustainability. One systematic review identified seven categories of implementation success factors: ethical, financial, functionality, organizational, political, technical and training. This case study applies this framework to iSanté, Haiti's national EMR in use in more than 100 sites and housing records for more than 750 000 patients. The author group, consisting of representatives of different agencies within the Haitian Ministry of Health (MSPP), funding partner the Centers for Disease Control and Prevention (CDC) Haiti, and implementing partner the International Training and Education Center for Health (I-TECH), identify successes and lessons learned according to the seven identified categories, and propose an additional cross-cutting category, sustainability. Factors important for long-term implementation success of complex information systems are balancing investments in hardware and software infrastructure upkeep, user capacity and data quality control; designing and building a system within the context of the greater eHealth ecosystem with a plan for interoperability and data exchange; establishing system governance and strong leadership to support local system ownership and planning for system financing to ensure sustainability. Lessons learned from 10 years of implementation of the iSanté EMR system are relevant to sustainability of a full range of increasingly interrelated information systems (e.g. for laboratory, supply chain, pharmacy and human resources) in the health sector in low-resource settings.

Challenges in data quality: the influence of data quality assessments on data availability and completeness in a voluntary medical male circumcision programme in Zimbabwe.

OBJECTIVES: To assess availability and completeness of data collected before and after a data quality audit (DQA) in voluntary medical male circumcision (VMMC) sites in Zimbabwe to determine the effect of this process on data quality. SETTING: 4 of 10 VMMC sites in Zimbabwe that received a DQA in February, 2015 selected by convenience sampling. PARTICIPANTS: Retrospective reviews of all client intake forms (CIFs) from November, 2014 and May, 2015. A total of 1400 CIFs were included from those 2 months across four sites. PRIMARY AND SECONDARY OUTCOMES: Data availability was measured as the percentage of VMMC clients whose CIF was on file at each site. A data evaluation tool measured the completeness of 34 key CIF variables. A comparison of pre-DQA and post-DQA results was conducted using χ2 and t-tests. RESULTS: After the DQA, high record availability of over 98% was maintained by sites 3 and 4. For sites 1 and 2, record availability increased by 8.0% (p=0.001) and 9.7% (p=0.02), respectively. After the DQA, sites 1, 2 and 3 improved significantly in data completeness across 34 key indicators, increasing by 8.6% (p<0.001), 2.7% (p=0.003) and 3.8% (p<0.001), respectively. For site 4, CIF data completeness decreased by 1.7% (p<0.01) after the DQA. CONCLUSIONS: Our findings suggest that CIF data availability and completeness generally improved after the DQA. However, gaps in documentation of vital signs and adverse events signal areas for improvement. Additional emphasis on data completeness would help support high-quality programme implementation and availability of reliable data for decision-making.

An assessment of data quality in a multi-site electronic medical record system in Haiti.

OBJECTIVES: Strong data quality (DQ) is a precursor to strong data use. In resource limited settings, routine DQ assessment (DQA) within electronic medical record (EMR) systems can be resource-intensive using manual methods such as audit and chart review; automated queries offer an efficient alternative. This DQA focused on Haiti's national EMR - iSanté - and included longitudinal data for over 100,000 persons living with HIV (PLHIV) enrolled in HIV care and treatment services at 95 health care facilities (HCF). METHODS: This mixed-methods evaluation used a qualitative Delphi process to identify DQ priorities among local stakeholders, followed by a quantitative DQA on these priority areas. The quantitative DQA examined 13 indicators of completeness, accuracy, and timeliness of retrospective data collected from 2005 to 2013. We described levels of DQ for each indicator over time, and examined the consistency of within-HCF performance and associations between DQ and HCF and EMR system characteristics. RESULTS: Over all iSanté data, age was incomplete in <1% of cases, while height, pregnancy status, TB status, and ART eligibility were more incomplete (approximately 20-40%). Suspicious data flags were present for <3% of cases of male sex, ART dispenses, CD4 values, and visit dates, but for 26% of cases of age. Discontinuation forms were available for about half of all patients without visits for 180 or more days, and >60% of encounter forms were entered late. For most indicators, DQ tended to improve over time. DQ was highly variable across HCF, and within HCFs DQ was variable across indicators. In adjusted analyses, HCF and system factors with generally favorable and statistically significant associations with DQ were University hospital category, private sector governance, presence of local iSante server, greater HCF experience with the EMR, greater maturity of the EMR itself, and having more system users but fewer new users. In qualitative feedback, local stakeholders emphasized lack of stable power supply as a key challenge to data quality and use of the iSanté EMR. CONCLUSIONS: Variable performance on key DQ indicators across HCF suggests that excellent DQ is achievable in Haiti, but further effort is needed to systematize and routinize DQ approaches within HCFs. A dynamic, interactive "DQ dashboard" within iSanté could bring transparency and motivate improvement. While the results of the study are specific to Haiti's iSanté data system, the study's methods and thematic lessons learned holdgeneralized relevance for other large-scale EMR systems in resource-limited countries.

A qualitative assessment of challenges to tuberculosis management and prevention in Northern Ethiopia.

OBJECTIVE: To elicit Ethiopian health care providers' understanding of challenges to effectively preventing, diagnosing and treating tuberculosis (TB). DESIGN: Qualitative data were collected via in-depth interviews and focus group discussions with 73 providers, including physicians, nurses, pharmacists and laboratory technicians, in five hospitals in the Northern Ethiopian regions of Amhara and Tigray. There was no intervention. RESULTS: Focus groups and interviews shared a number of prominent common themes. Respondents identified numerous challenges associated with active case identification, infection control practices, diagnostics, including the absence of TB culture and drug susceptibility testing capacity, and the lack of infrastructure for diagnosing and treating multidrug-resistant TB. Pharmacists noted a need for improved procurement practices and pediatric dosages for TB medications. Providers shared concerns regarding isoniazid preventive therapy, health workforce challenges and the risk of contracting TB in the workplace. CONCLUSIONS: Health care providers in the Northern Ethiopian regions of Tigray and Amhara identified many challenges to effectively preventing, diagnosing and treating TB. These challenges are complicated by severe resource constraints and challenges in attracting and retaining providers in government hospitals in centers outside Addis Ababa.

Nonlinear mixed effects pharmacokinetic/pharmacodynamic analysis of the anticonvulsant ameltolide (LY201116) in a canine seizure model.

The anticonvulsant ameltolide (LY201116) is a novel potential therapy for the treatment of canine epilepsy. Eight dogs were administered five different oral doses of ameltolide and clinical scoring of the maximal electroshock (MES) induced seizures at 3 and 24 h postdosing were determined in two separate crossover design studies. Plasma ameltolide concentrations were determined at the time of seizures in all dogs and complete plasma concentration-time profiles were also determined in a separate study. A nonlinear mixed effects PK/PD model was fit to the resulting data. A one compartment open model with first order absorption was determined to best fit the ameltolide pharmacokinetics. An effect compartment with a cumulative logistic regression equation was used to establish the PK/PD relationship. The mean bioavailability normalized volume of distribution and the elimination half-life were estimated at 1.20 L/kg and 5.46 h, respectively. The fitted model estimated that from 2 to 15 h following a single 3 mg/kg oral ameltolide dose the mean probability of obtaining a 1 unit reduction in the seizure clinical score severity was greater than 0.80. The utilized PK/PD analysis combined with the canine MES model allowed for the rapid and efficient determination of the plasma ameltolide concentration-anticonvulsant relationship preclinically in dogs.

Development and validation of the maximal electro-shock seizure model in dogs.

The development and validation of the maximal electro-shock (MES) model using phenobarbital (Pb) as the positive control is described. This approach builds on previous work in rodent model systems, and has been adapted to dogs as a tool for pharmaceutical dose selection. Dogs, like rodents, exhibit generalized convulsions which manifest as progressive clinical signs in a dose (electrical current) dependent fashion. At the limit (300 mA, 200 msec) animals underwent clonic-tonic convulsions consistent with complete generalized (Grand Mal) seizures with a grade 3 clinical score (CS) and a menace response time of 98.5 +/- 24.4 sec (n = 8). Pretreatment of animals with Pb at 3, 10, and 30 mg/kg, in a 4-by-4 complete block crossover design (Latin-Square), resulted in a dose-dependant reduction in CS and menace response time. Estimates of plasma Pb concentration taken prior to MES induction showed a similar dose-dependent reduction in CS and menace response time with concentration. Using a cumulative logistic regression model, a predicted 50% probability of a CS = 1 was approximately 11.4 mg/kg. In addition, plasma Pb concentrations predicted a 50% probability of a CS = 1 occurs at plasma Pb concentration of approximately 16.0 mug/mL. Combined these data suggest that MES is a useful model for evaluating generalized convulsions in canines and may provide a tool for dose selection of novel pharmaceutical compounds.

Effects of stocking rate and corn gluten feed supplementation on performance of young beef cows grazing winter-stockpiled tall fescue-red clover pasture.

A winter grazing experiment was conducted to evaluate the effects of stocking rate and corn gluten feed supplementation on forage mass and composition and the BW and BCS of bred 2-yr-old cows grazing stockpiled forage during winter. Two 12.2-ha blocks containing Fawn, endophyte-free, tall fescue and red clover were each divided into 4 pastures of 2.53 or 3.54 ha. Hay was harvested from the pastures in June and August of 2003 and 2004, and N was applied at 50.5 kg/ha at the initiation of stockpiling in August. On October 22, 2003, and October 20, 2004, twenty-four 30-mo-old Angus-Simmental and Angus cows were allotted by BW and BCS to strip-graze for 147 d at 0.84 or 1.19 cow/ha. Eight similar cows were allotted to 2 dry lots and fed tall fescue-red clover hay ad libitum. Corn gluten feed was fed to cows in 2 pastures to maintain a mean BCS of 5 (9-point scale) at each stocking rate and in the dry lots (high supplementation level) or when weather prevented grazing (low supplementation level) in the remaining 2 pastures at each stocking rate. Mean concentrations of CP in yr 1 and 2 and IVDMD in yr 2 were greater (P < 0.10) in hay than stockpiled forage over the winter. At the end of grazing, cows fed hay in dry lots had greater (P < 0.05) BCS in yr 1 and greater (P < 0.10) BW in yr 2 than grazing cows. Grazing cows in the high supplementation treatment had greater (P < 0.10) BW than cows grazing at the low supplementation level in yr 1. Cows in the dry lots were fed 2,565 and 2,158 kg of hay DM/cow. Amounts of corn gluten feed supplemented to cows in yr 1 and 2 were 46 and 60 kg/ cow and did not differ (P = 0.33, yr 1; P = 0.50, yr 2) between cows fed hay or grazing stockpiled forage in either year. Estimated production costs were greater for cows in the dry lots because of hay feeding.

Comparison of local risk factors for children's atopic symptoms in Hanoi, Vietnam.

BACKGROUND: A 1999 study in Hanoi, Vietnam using the International Study on Asthma and Allergies in Childhood (ISAAC) questionnaire showed a high prevalence of atopic symptoms. Identifying risk factors for symptoms in these children may help in understanding the causes for these high estimates. METHODS: An ISAAC questionnaire with supplemental questions on environmental variables was distributed to 5495 school children in Hanoi and a suburban district, Dong Anh. The response rate was 65.7%. RESULTS: In Dong Anh, the following were among the significant age and gender adjusted associations: pig ownership [odds ratio (OR) (95% confidence interval), OR = 1.79 (1.18-2.70) for doctor-diagnosed asthma (DDA), OR = 1.72 (1.08-2.78) for doctor diagnosed hay fever (DDHF)] and farming [OR = 1.67 (1.27-2.19) for ever asthma, OR = 1.51 (1.09-2.09) for DDHF]. In multivariate models, tuberculosis (TB) was a significant predictor of atopic symptoms [Hanoi: OR = 3.09 (1.10-8.70) for DDA, Dong Anh: OR = 3.71 (1.40-9.84) for DDA, OR = 4.66 (1.88-11.57) for DDHF]. CONCLUSIONS: These findings are contrary to the "hygiene hypothesis". Recent immunologic and epidemiologic studies refute the inverse association between allergy and TB and may be one explanation for the positive association in this study. The positive association with pig ownership and farming may be because of exposures on farms in a developing country that may be different from exposures in farms of developed countries.

Evaluation of hay-type and grazing-tolerant alfalfa cultivars in season-long or complementary rotational stocking systems for beef cows.

Alfalfa (Medicago sativa L.) persistence and forage and cow-calf production were evaluated on pastures containing smooth bromegrass with or without grazing-tolerant or hay-type alfalfa cultivars rotationally stocked in either a season-long or complementary system. In 1997, six 2.02-ha pastures were seeded with smooth bromegrass, a mixture of a grazing-tolerant alfalfa (Amerigraze variety) and smooth brome-grass, or a mixture of a hay-type alfalfa (Affinity variety) and smooth bromegrass to be used in season-long stocking systems. Four 2.02-ha pastures were seeded with smooth bromegrass on 1.21 ha of each pasture, and mixtures of either the grazing-tolerant or hay-type alfalfa cultivars and smooth bromegrass on the 0.81 ha of each pasture to be used in complementary stocking systems. All 10 pastures were divided into 10 paddocks and rotationally strip-stocked at 1.98 cow-calf units/ha with crossbred cows and calves for 120 and 141 d starting May 18, 1998 (yr 1), and May 6, 1999 (yr 2), respectively. Each year, first harvest forage was harvested as hay from 40% of all 10 pastures, this being the portions of the pasture seeded with the alfalfa-smooth brome-grass mixtures for pastures with the complementary stocking systems. In yr 1 and 2, the remaining 60% of each pasture was grazed for the first 44 and 54 d, and 100% of each pasture was grazed on d 45 to 120 and d 55 to 141, respectively. Proportions of alfalfa in the live dry matter of pastures seeded with the grazing-tolerant and hay-type alfalfa cultivars decreased by 70 and 55% in paddocks stocked season-long and by 60 and 42% in paddocks used for complementary stocking (alfalfa cultivar, P < 0.05; stocking system, P < 0.05) in yr 1, but decreased by 72% across cultivars and stocking systems in yr 2. Total (P < 0.08) forage masses in September of yr 1 and in August of yr 2 were greater in pastures in which alfalfa paddocks were stocked season-long than in those with complementary alfalfa stocking. Grazing of alfalfa in grass mixtures increased calf and total cow/calf weight gains in comparison with grazing of smooth bromegrass, but alfalfa persistence, measured as a proportion of the live dry matter, was not affected by alfalfa cultivar.

An occupational risk survey of a refractory brick company in Ha Noi, Viet Nam.

Viet Nam has an increasing need for building materials, including refractory bricks. Little is known regarding the occupational hazards incurred in brick manufacturing. To determine the occupational health hazards posed by a refractory brick operation in Ha Noi, Viet Nam, a cross-sectional occupational risk survey was conducted, focusing on respirable dust hazards. It included an industrial hygiene walk-through and gravimetric dust analysis. Noise, heat, lack of head protection, and dust exposure were hazards identified at the brick-manufacturing site. Respiratory protection involved a three-layer cloth mask that had not been tested for efficacy. Silica dust exposure levels exceeded the Vietnamese permissible exposure level by almost fivefold based on gravimetric assessment and estimated silica content. This brick manufacturing site contains significant injury and respiratory illness hazards. Further investigations are necessary to begin to develop occupational safety measures at the site.

An evaluation of factors affecting hazardous waste workers' use of respiratory protective equipment.

The purpose of this study was to describe the perceptions of a group of hazardous waste workers about their workplace hazards and to understand their beliefs and attitudes about the use of respiratory protective equipment (RPE). There were two phases of data collection: (1) interviews to identify factors that influence respirator use and (2) a written survey to evaluate the importance of these factors. This article describes the findings from the written survey completed by 255 eligible respondents (return rate = 46.5%, 255/548). Subjects used a weighting system to score 18 identified factors that influence the use of RPE. Scores were compared according to type of respirator, frequency of use, and associated health symptoms. The factors that had the most positive influence on respirator use were concern about work exposure, fit-testing, and training. The most negative influences were communication, personal comfort, effect on vision, structural environment, and fatigue. More frequent users (once per month or more) were significantly more likely to view fit-testing, health effects, and effects on vision negatively than were less frequent users. Persons who reported health symptoms associated with respirator use had more negative scores than persons without health symptoms. Workers categorized as laborers were more likely to be frequent respirator users and to wear supplied-air respirators, and were significantly more likely to view vulnerability to disease negatively, than were other worker groups. The findings from this study indicate that respiratory protection programs must extend beyond training and education; to be maximally effective, health professionals must be responsive to the specific concerns of the workers.

Pediatric environmental health: perceptions from a survey questionnaire.

To expand the base of knowledge regarding perceptions about potential environmental threats to children's health, a survey was conducted in the Northwest United States. Samples of Head Start parents, PTA presidents, public health officials, school nurses, naturopathic physicians, family practitioners, and pediatricians were mailed a questionnaire inquiring into the nature and degree of concerns about pediatric environmental health. The response rate was 24%. Trends in the data showed disparities in perceptions regarding levels of concern and exposure concerns between respondent categories. Disparities also existed regarding information resources used for children's environmental health. Recognizing differences in perceptions of children's environmental health, as demonstrated in these results, may be useful for risk communication and resource allocation, especially in the context of the wide variety of health belief models. Such knowledge may help clarity situations with environmental health risk concerns, including clinical, public health, and educational circumstances.

The respiratory effects of volatile organic compounds.

Volatile organic compounds (VOCs) have been implicated as causative agents in asthma and building-related illness. To determine whether a mixture of VOCs could impair lung function or cause airway inflammation among subjects without bronchial hyperresponsiveness, the authors conducted a randomized, crossover-design trial of controlled human exposures to filtered air for four hours, VOCs at 25 mg/m(3) for four hours, and VOCs at 50 mg/m(3) for four hours, using a VOC mixture based on sampling of indoor environments. VOC exposures caused dose-related increases in lower respiratory, upper respiratory, and non-respiratory symptoms, with no significant change in lung function (FEV(1);, FVC, or FEF(25-75), nasal lavage cellularity or differential cell counts, induced sputum cellularity or differential cell counts, or biomarkers of airway inflammation, including IL-8, LTB(4), or albumin in nasal lavage or induced sputum samples. Atopic individuals had significantly reduced FEE(25-75 following exposure to VOCs at 50 mg/m(3), suggesting that these individuals may be more sensitive to the health effects of VOCs. The authors conclude that reductions in levels of VOCs to substantially less than 25 mg/m(3) are required if a "non-irritating" work environment is desired.

Barriers and solutions in implementing occupational health and safety services at a large nuclear weapons facility.

The Hanford Nuclear Reservation is one of the U.S. Department of Energy's largest nuclear weapons sites. The enormous changes experienced by Hanford over the last several years, as its mission has shifted from weapons production to cleanup, has profoundly affected its occupational health and safety services. Innovative programs and new initiatives hold promise for a safer workplace for the thousands of workers at Hanford and other DOE sites. However, occupational health and safety professionals continue to face multiple organizational, economic, and cultural challenges. A major problem identified during this review was the lack of coordination of onsite services. Because each health and safety program operates independently (albeit with the guidance of the Richland field operations office), many services are duplicative and the health and safety system is fragmented. The fragmentation is compounded by the lack of centralized data repositories for demographic and exposure data. Innovative measures such as a questionnaire-driven Employee Job Task Analysis linked to medical examinations has allowed the site to move from the inefficient and potentially dangerous administrative medical monitoring assignment to defensible risk-based assignments and could serve as a framework for improving centralized data management and service delivery.

Structure and function of occupational health services within selected Department of Energy sites.

The mission of the United States Department of Energy sites has recently changed from nuclear weapons production to site remediation. Considering the mass of radiological and chemical contaminants at these sites, ensuring the health and safety of workers is a major challenge. This study used the findings from a written survey to describe occupational health services at 10 Department of Energy sites. The study aims were to describe and compare: (1) the primary hazards associated with the site activities; (2) the occupational safety and health structure, including service providers; and (3) the occupational health and safety functions, including surveillance, training, and service provision. Although explosions and radiological agents were identified as the hazards with the greatest associated risks, workers at these sites were most likely to be exposed to physical hazards, ergonomic hazards, and/or chemicals, including asbestos. Physicians accounted for 2.4% of service providers, nurses for 5.5%, industrial hygienists for 12.2%, safety personnel for 11.8%, and health physicists for 64.9%. It was concluded that there is an imbalance between the most important hazards and the types of health and safety personnel at these sites.

A description of factors affecting hazardous waste workers' use of respiratory protective equipment.

This article describes the first phase of a study that was designed to gain an understanding of hazardous waste workers' attitudes and beliefs about the use of respiratory protective equipment. Exploratory, open-ended interviews were conducted among 28 respirator users at a US Department of Energy facility. Subjects were asked to describe their knowledge, attitudes, and beliefs about their risks to hazards at their worksites and to discuss their use of respiratory protective equipment. A detailed content analysis of the interviews resulted in the generation of a taxonomy of issues and concerns which fell into three general categories: 1) Knowledge, Beliefs, and Attitudes, 2) Physical and Psychological Effects, and 3) External Influences. Knowledge, Beliefs, and Attitudes included Training, Fit Testing, Medical Clearance, Work Exposures, Respirator Use, and Vulnerability to Disease. Physical and Psychological Effects included Somatic/Health Effects, Personal Comfort, Visual Effects, Fatigue, Communication, and Anxiety. External Influences included Structural Environment, Quality and Availability of Equipment, Other PPEs, Co-Worker Influence, Supervisor Influence, and Organizational Culture. The findings from this study have important implications to training and education programs. Effective respiratory protection programs depend on a knowledge of the factors that affect workers' use of equipment. This study suggests that efforts to assure equipment comfort and fit, to assist workers who see and hear less well as a result of their equipment, and to develop strategies to allay worker anxiety when wearing equipment should all be components of a program. An organizational culture that supports and abets the appropriate use of equipment is also a critical element in a successful program.

Hyperventilation following a large-scale hazardous-materials incident.

Actual or perceived exposure to hazardous materials may result in physiologic and psychological effects. However, hyperventilation following such exposures has not previously been reported. After a large-scale industrial release of oxides of nitrogen, five (29%) of 17 patients evaluated at a major trauma center were hyperventilating, as defined by arterial PCO2 <33 mm Hg, and nine patients (53%) had arterial PCO2 <37 mm Hg. First responders (rescue team members and paramedics) had a higher rate of hyperventilation than other occupational groups. Age, gender, marital status, decontamination, and mode of arrival were not significantly associated with hyperventilation, although marital status approached significance. This study suggests that hyperventilation may be a common reaction after hazardous-materials incidents, and that certain populations may be at increased risk for this condition.

Disorders of proprioceptive responses in monkeys after cerebellar lesions: an analysis using the Denny-Brown Collection.

We used the Denny-Brown Research Collection to study in detail the reflex responses of monkeys after ablation of the anterior lobe, posterior lobe or the entire cerebellum. The Collection includes written, film and histological records, and photographs of the brain at autopsy. Large cerebellar ablations severely suppress proprioceptive responses, thereby significantly impairing the capacity to stand, walk, and hop. Cutaneous reflexes are also impaired, although more selectively, permitting expression of normally suppressed responses such as magnet reactions and tactile avoiding responses. Enhancement (release) of responses to truncal cutaneous stimulation, along with suppression of opposing proprioceptive responses, leads to postures of persistent flexion. Large cerebellar lesions also interfere with reflex responses mediated by visual and vestibular systems. More limited cerebellar ablations have similar, but less severe effects.

Respiratory protective devices: rates of medical clearance and causes for work restrictions.

BACKGROUND: There are no published data on the outcomes and benefits of medical evaluations for the use of respiratory protective devices. We, therefore, conducted a retrospective database and chart review to assess the rates of medical clearance and causes for work restrictions at a Department of Energy complex. METHODS: All workers with work restrictions or denied clearance over a one-year period were identified and their medical records abstracted. RESULTS: Of the 5,569 workers who received medical evaluation, only 71 (1.3%) received limitations on respirator use documented in their medical record. Of the 65 workers with sufficient medical records for additional analysis, 9 of the 5,569 workers (0.2%) were denied medical clearance, while 56 workers (1.1%) received work restrictions. Pregnancy was the most common cause for denying medical clearance for respirator use. Lung disease, cardiovascular disease, and claustrophobia were the most common causes for work restrictions. Physical examination and spirometry added little to the detection of relevant medical conditions. CONCLUSIONS: We conclude that few workers fail medical clearance for respirator use or receive work restrictions. Data on adverse events from respirator use are needed to help design appropriate medical evaluations and uniform criteria for work restrictions or denial of medical clearance.

Medical clearance for respirator use: sensitivity and specificity of a questionnaire.

BACKGROUND: OSHA regulations require that workers receive medical clearance prior to respirator use, and recently, a detailed questionnaire has been provided to assist with this purpose. However, there are limited published data on the sensitivity and specificity of self-administered questionnaires for identifying individuals who may safely wear a respirator. METHODS: We tested 474 consecutive workers at a Department of Energy complex. After completing the self-administered questionnaire, all workers received a standardized physician evaluation including interview, physical examination, and spirometry. The outcomes of the questionnaire assessment were compared to the outcomes of physician evaluation. RESULTS: Data for analysis were available from 413 of workers (87%). All workers received medical clearance; only 10 workers (2.4%) received work restrictions. The questionnaire demonstrated 100% sensitivity in identifying workers who required work restrictions, but had specificity of only 19%. Compared to physician evaluation, the questionnaire had modest sensitivity to the detection of chronic medical conditions. CONCLUSIONS: These data suggest that the rates of medical clearance for respirator use are very high, and that a self-administered questionnaire may be appropriate for medical clearance in certain settings. It is recommended that the policy of routine physician evaluation and spirometry for respirator clearance be re-examined.